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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345920167
Report Date: 12/04/2024
Date Signed: 12/04/2024 09:58:06 AM

Document Has Been Signed on 12/04/2024 09:58 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:BLOSSOM RESIDENTIAL IIFACILITY NUMBER:
345920167
ADMINISTRATOR/
DIRECTOR:		SOLOVYEV, RALUCAFACILITY TYPE:
740
ADDRESS:8967 AMORUSO AVETELEPHONE:
(916) 254-9557
CITY:FAIR OAKSSTATE: CAZIP CODE:
95628
CAPACITY: 6CENSUS: 0DATE:
12/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Raluca SolovyevTIME VISIT/
INSPECTION COMPLETED:
10:10 AM
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Licensing Program Analysts (LPAs) Cassandra Mikkelson and Michael Hood met with Administrator, Raluca Solovyev, to conduct a Pre- Licensing visit. The facility has a fire clearance for six (6) non-ambulatory residents. Administrator Raluca Solovyev has an active certificate (#7022001740 with expiration date 03/09/2026).

LPAs conducted an inspection of the care home to ensure compliance with Title 22 regulations. There are four (4) bedrooms and three (3) bathrooms for resident use and one (1) staff room. Bathrooms were in sanitary condition and properly maintained. Hot water temperature was observed to be 117.5 degrees F. LPAs observed facility has the ability to prepare and store food, to lock away cleaning products and other toxins, and lock medications to make inaccessible to residents. LPAs observed smoke detectors and carbon monoxide detectors at the care home to be operational.

Component III was waived. Application is pending and LPAs will forward findings to the Centralized Application Bureau (CAB) for final review and approval. CAB will further contact applicant on final status of application. A copy of this report was provided to the facility. Exit interview conducted.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassandra Mikkelson
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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